Patient Registration Form

Patient Information

Name

Date of Birth

Sex

M F

Doctor

Address

Same as primary guardian?

Y N

If No, who does this child live with?

Race

White BIack/African American Asian American Indian/Alaskan Native Not Provided

Ethnicity

Hispanic or Latino Non-Hispanic or Latino Not Provided

Preferred Language

Primary Parent/Guardian

Please list parents/guardians separately regardless of marital or custodial status

Name

SSN

Date of Birth

Address

City

State

Zip

Please check box of preferred phone method for reaching you

Home Phone

Cell Phone

Home Phone

Cell Phone

Marital Status Please choose all that apply

Married

Divorced/Sep.

Full Custody

Shared Custody

N/A

If married, please indicate name

If Divorced/Separated, please indicate name

Relationship to Patient(s)

I am the individual filling out this form

Financially Responsible

Secondary Parent/Guardian:

Name

SSN

Date of Birth

Address

City

State

Zip

Please check box of preferred phone method for reaching you

Home Phone

Cell Phone

Home Phone

Cell Phone

Marital Status Please choose all that apply

Married

Divorced/Separated

Full Custody

Shared Custody

N/A

If married, please indicate name

If Divorced/Separated, please indicate name

Relationship to Patient(s)

I am the individual filling out this form

Financially Responsible

Other Parent/Guardians/Emergency Contacts

Add additional individual

Siblings

Add sibling

Pharmacy Information

Name

Address/Crossroads

Phone

Insurance Information

Primary Insurance Company

Member ID # / Group #

Subscriber Name

Date of Birth

Note: If secondary insurance applies, please provide that information below. Both insurance parties must be made aware that the other exists. If they do not, please contact necessary parties. Medicaid is always secondary to commercial insurance.

Secondary Insurance Company

Member ID # / Group #

Subscriber Name

Date of Birth

Pharmacy Authorization

I hereby authorize Ocoee Pediatrics to electronically send prescriptions to a participating pharmacy of my choice. Ocoee Pediatrics may electronically receive information regarding my child’s prescription history, drug interactions, prior authorization requirements, or requested substitutions.

Authorization and Consent for Treatment, Assigning of Benefits, Financial Responsibility, HIPAA Acknowledgment

I hereby authorize Ocoee Pediatrics to provide medical services to the above named patient and to use and release medical information as required for treatment and health care operations. I hereby authorize Ocoee Pediatrics to furnish my insurance company all they may request concerning the patient’s present illness or injury. I hereby assign to Ocoee Pediatrics all benefits for service rendered. I understand that failure to make insurance co-payments at the time of service will result in additional charges. I have received or reviewed a copy of the current Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

PLEASE READ CAREFULLY PATIENT-DOCTOR AGREEMENT

Missed/Changing Appointments

We schedule appointments according to urgency and availability.

In order to receive the maximum benefit from care; it is important to adhere to this schedule. Please arrive at, or just before, your appointment time.

If you find that you are running late, please call our office to determine if we can hold your appointment.

If for any reason you are unable to keep your scheduled appointment, you must give our office 24 hour notice or you will be charged a $50.00 service fee.

Patients that miss 3 appointments without cancellation will be discharged from this practice.

Office Policy

No food or drink (excluding water) in the office.

No cell phone use allowed while interacting with the staff or physicians

Insurance Authorization and Assignment of Benefits

I authorize and request that insurance payments be made directly to this office and any medical payment from the patient's insurance for services rendered.

Patient understands that if she/he suspends or terminates care, any fees for services rendered to patient will be immediately due and payable.

Payment Policy

I acknowledge full financial responsibility for services rendered and I understand payment for services are due on the day of service.

This includes co-payments and payment for medical forms.

Any balance that is left unpaid for over two billing cycles is subject to a $10.00 late fee.

This late fee will be applied to any unpaid amount.

If a check has been written for payment and the check is returned for insufficient funds, there will be a $35.00 fee added to your current balance.

Communication

We are here to serve you. Please speak to us about any concerns that may arise at any time. By communicating how you experience care in our office, you enable us to provide you with the best care possible. Thank you!

By signing below, I indicated that I have read the above policies and agree to the applicable conditions. I consent treatment, financial responsibility and insurance authorization.

Patient portal is available to access your information, limited medical records and forms.

Parent Signature

Date

Delegation of Consent

Name of Patient

Patient’s Date of Birth

I hereby authorize (when I am unavailable to give consent) to the following individual(s):

Add Authorized Person

to consent to any and all medical care and attention for this child which is deemed necessary and appropriate by a healthcare provider licensed in the state of Florida. This consent includes, but is not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw delegation of consent.

Signature of Parent/Guardian/Patient (if 18 years or older)

Relationship to Child

Date

Witness

Translator/Reader (if applicable)

Authorization to Obtain Medical Records

Records to be Released To

Ocoee Pediatrics

1551 Boren Drive, Suite A

Ocoee, FL. 34761

P: 407-395-2037 F: 407-395-2038

Records to be Released From

Office/Doctor

Address

Phone/Fax

Patient Information

Patient Name

Address

Date of Birth

Phone

I understand that:

I may revoke this authorization at any time in writing, except to the extent that action has been taken based upon it;
The recipient of these records may further disclose this information and it may then no longer be protected by federal privacy regulations;
I am entitled to a copy of this document;
I may refuse to sign this authorization and my refusal to sign will not affect treatment, payment, enrollment, or eligibility for benefits;
There may be a charge for the release of these records pursuant to 45 CFR 164.524 (c) (4) (HIPAA);
This authorization shall expire upon my written request to revoke or according to state law;
A copy of this Authorization is valid as the original

Signature of Patient or Patient Representative

Date

Description of Representative’s Authority to Act for Patient

Preferred Contact Methods

Contact Parent Name

What is the best phone number to reach you?

Would you like appointment reminders by text at above number?

If no, how would you like appointment reminders?

Can we leave messages at above number?

Would you like to register for patient portal?

Email for portal:

Please list all children this applies to

Add Child

New Patient History Form

Date

Name of Patient

Date of Birth

How were you referred to our practice?

Allergies (Medications, Vaccines, Food, others)

Current Medications

BIRTH HISTORY

Full Term

Pre-term

Adopted

If Pre-term, how many weeks?

If Adopted, at what age?

Type of Delivery

Vaginal C-Section

Breech presentation?

Yes No

If C-section, why?

Any problems during newborn period?

Birth weight

Passed hearing screen?

Passed PKU/Newborn screen?

CHILD’S PAST MEDICAL HISTORY – please mark yes and no, with brief explanation

Any Hospitalizations?

Any Surgeries?

Any Emergency room or urgent care visits?

HAS YOUR CHILD EVER BEEN TREATED FOR ANY OF THE FOLLOWING:

ADHD/ADD

Yes No

Allergies

Yes No

Asthma

Yes No

Eczema

Yes No

Seizures

Yes No

Heart Murmur/Heart Condition

Yes No

Wheezing

Yes No

Ear Infections

Yes No

Chicken Pox

Yes No

Urinary tract infection

Yes No

Serious injury or concussion / Broken Bones

Yes No

Vision/Glasses

Yes No

Developmental and/or speech problems

Yes No

For girls only, has she started her menstrual cycle?

Yes No

Check if none of the above applies

Other medical history?

Has your child ever been seen by specialist? List:

HAS YOUR CHILD EVER HAD….

Fainting during or after exercise, emotion or startle?

Extreme Shortness of breath with exercise?

Discomfort, pain or pressure in chest during exercise?

FAMILY HISTORY

Do any family members have any of the following conditions?

High Blood Pressure

Mother

Father

Sibling

Grandparent

Aunt/Uncle

High Cholesterol

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Prolonged QT

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Early heart attack (under age 50)

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Sudden unexplained death

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Anemia

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Bleeding or clotting disorder

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Allergies

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Autoimmune disorder

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Cancer

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Development/Genetic disease

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Diabetes

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Thyroid Disease

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Deafness

Mother

Father

Sibling

Grandparent

Aunt/Uncle

ADD/ADHD

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Migraines

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Seizures

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Mental Illness

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Drug/alcohol abuse

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Asthma

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Tuberculosis

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Kidney problems

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Hip dysplasia

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Other

Mother

Father

Sibling

Grandparent

Aunt/Uncle

If other, please list here.

Social History

Who lives in your child’s home?

If parents are not living together or if child does not live with parents, do both parents have custody? Are both parents involved in care?

Any Smokers?

Any Pets?

Form completed by

Relationship to child

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